Caudal Duplication Syndrome: the Vital Role of a Multidisciplinary Approach and Staged Correction

Caudal duplication syndrome: 10-year experiences with a comprehensive literature review

PURPOSE

Caudal duplication syndrome (CDS) has rarely been reported. The purpose was to describe the characteristics and discuss possible pathogenesis of CDS by reviewing our experience along with a comprehensive literature review.

METHODS

A total of 51 patients including 3 from our team and 48 from literature were selected in this study. General condition, clinical manifestations, type of anomalies, treatment and prognosis was analyzed and summarized.

RESULTS

Among the 51 patients were 30 females and 21 males, and age at first clinical visit was from birth to 39 years old. Except 12 patients, most of the patients had no troubling clinical manifestation. Physical examination showed that 30 patients had 1 perineum, 21 patients had 2 completely independent perineums. Degree of duplication varied; colon-rectum tubular, bladders and urethras, vaginas in females and penis shafts and glans in males were found to be the most common type of alimentary system and urogenital system duplication in this study with 24/51, 41/51, 10/30 and 16/21 patients, respectively. Anorectal malformation was calculated: 18 had 2 ARMs, 14 had 1 normal anus and 1 ARM on the other side, 12 had a normal anus, 5 had 2 normal anus, the remaining 2 patients had only 1 ARM. Spinal cord anomalies were showed as meningomyeloceles and lipomas in 13 and 3 patients. Vertebral anomalies of bifid, dysplasias, scoliosis, and hemivertebra were noticed in 28 patients and accessory dysplasia lower limbs were found in 10 patients. Prognosis showed 39 of the 51 patients had normal function in urination and defecation.

CONCLUSIONS

CDS is an extremely rare disease with uncertain pathogenesis. Colon-rectum tubular duplication with two ARMs, duplicated bladders and urethras, double vaginas in females and penis shafts and glans in males are the most common type. Long-term prognosis is good with multidisciplinary, individualized and staged surgical procedures.

Complete Colonic Duplication and Perineal Fistula: Transanal Mucosectomy of the Ectopic Rectum

Background Colonic duplication may present in different anatomic variants. The surgical approach towards these anomalies can be challenging and has implications for subsequent future continence.

Case Description  We report on a 1-year-old girl with congenital heart defect and pacemaker who was referred to us with an anorectal malformation. The patient was stooling from both an anus and a perineal fistula. Examination under anesthesia revealed an orthotopic and age-appropriate sized anus with surrounding sphincter and a second rectal lumen ending as a perineal fistula. A computed tomography and contrast enema indicated colonic duplication. Exploratory laparotomy showed a duplicated terminal ileum leading to two ceca and appendices, which joined to a duplicated colon with a septum and common mesentery. At the rectosigmoid junction, one part of the duplication ended as a perineal fistula, the second one led to the (orthotope) anus. The common colonic wall was divided using a stapler. The rectal duplication leading to the perineal fistula was not completely resected but treated by mucosectomy only (Soave plane) leaving its muscular cuff in place. Finally, an ileostomy was created. The postoperative course was uneventful. A contrast enema prior to ostomy takedown demonstrated a well-configurated colon and rectum without stenosis or impaction. The girl is currently continent with a complete resolution of her constipation.

Conclusion  In cases of complete colonic duplication division of the common wall is simple and safe. Mucosectomy of the ectopic rectum limits pelvic dissection and preserves the entire muscular wall of the duplicated orthotope rectum.

Caudal duplication syndrome: a literature review and reappraisal of its pathoembryogenesis

INTRODUCTION

The term caudal duplication syndrome (CDS) was first introduced for complex anomalies of the distal caudal end of the trunk. The pathoembryogenesis of CDS is yet unknown, although a few theories have been proposed. We reviewed the previously proposed pathoembryogenetic theories and suggested a new perspective through the common clinical characteristics shown in CDS cases reported in the literature.

METHODS

We conducted a systematic literature search of the online database PubMed from October 1993 to October 2020, using the search term "caudal duplication syndrome", according to the first mention of this entity. A total of 17 articles with 23 patients were reviewed.

RESULTS

The most common manifestations were the duplication of the distal colon, genitourinary organs, and lower spine. Specifically, the duplicated bladders or uteri contacted their counterpart through a septum, and the duplicated bowels ran parallel. More caudal structures, such as the urethra or anus, were formed separately. The duplication seems to be a result of division by an intervening septum or structure in each part. In addition, duplication was not limited to the structures formed from the caudal cell mass (CCM), such as the distal spine and spinal cord, but also included hindgut structures. Moreover, anomalies involving caudal mesenchymal defects were also present. Considering clinical manifestations that are related to all three germ layers and seemingly the overseptation of these germ layers in CDS patients, with supporting data from animal experiments, events such as late-stage errors involving Hensen's node/the primitive streak and the duplication of the CCM with the hyperplasia of the abnormally located central caudal mesenchyme are probable pathoembryogenetic mechanisms for CDS. The "leakage" of the normal growth power of the caudal mesenchyme into the intervening midline space between the two CCMs and consequent weak lateral and caudal pushes of the caudal mesenchyme may explain the association of caudal agenesis or its related anomalies with CDS.

CONCLUSION

We propose a theory that by a molecular interaction, an insult causes late gastrulation phase problems, resulting in ectopic primitive streak formation, and therefore, a duplication of the CCM is induced. Subsequently, the overactivity of abnormally positioned midline mesenchyme between the two CCMs may divide the hindgut derivatives by a central septum. Underactive lateral and caudal pushes of the caudal mesenchyme may lead to an association of features shown in caudal agenesis.

Caudal Duplication Syndrome Systematic Review-A Need for Better Multidisciplinary Surgical Approach and Follow-Up

Background and Objectives: Caudal duplication syndrome is a rare association of anatomical anomalies describing duplication of the hindgut, spine, and uro-genital structures, leading to varied clinical presentations. The current literature focuses on case reports which describe the embryological etiology and anatomical spectrum of the condition giving little attention to the surgical preparation, the need for a well-structured follow-up program, or the transition into adult healthcare of these complex patients. No reviews have been published regarding this complex pathology. Materials and Methods: A review of caudal duplication syndrome cases was done to assess the range of the clinical malformations, timing, and types of surgical interventions. Inconsistencies in multidisciplinary care, follow-up, and risk events were described. Results: Hindgut duplication always involved the anorectal region. Anorectal malformations were evenly distributed as unilateral and bilateral. Colon duplication extended from the anal region to the transverse colon or ascending colon in most of the cases and less to terminal. In females, genital duplication was present in all cases. The follow-up period varied between 3 months and 12 years. In all adult females, the motive of presentation was related to pregnancy (complications after successful delivery, fertility evaluation) or late complications (fecalith obstruction of the end-to-side colon anastomosis, repeated UTIs with renal scarring). Conclusions: Complex malformations affecting multiple caudal organs may have a strong impact in many aspects of the long-term quality of life; therefore, patients with caudal duplication syndrome need increased awareness and joined multidisciplinary treatment.

Caudal duplication syndrome in an adolescent: Rare concoction of duplication anomalies

Caudal duplication syndrome is a rare and interesting entity with a reported prevalence of <1/100,000 births. Caudal duplication syndrome encompasses a diverse spectrum of anomalies primarily involving partial or complete duplication of organs comprising the gastrointestinal, genitourinary and distal neural tube systems. The term 'caudal duplication syndrome' was coined by Dominguez et al. in 1993, in a case series of six patients presenting with findings pertaining to duplication anomalies of genitourinary system, hindgut, lumbosacral spine and cord. We here report a unique case of caudal duplication presenting in late adolescence and briefly review the available literature on this rare abnormality.

Newborn with complete double penis and two separate scrotums: A case report

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CDS is a very rare congenital anomaly that includes duplication of distal body organs.

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Our case has a complete double penis with two separate scrotums.

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Colostomy with 4 stomas was done for duplicated colon.

Introduction

We present a newborn with double penis and double scrotum as a part of a caudal duplication syndrome (CDS) which is a condition includes duplication of the distal organs of the body. It is crucial to have knowledge about it to be able to be identified.

Presentation

A male newborn presented with double penis, double scrotum double urethra, double colon, and double imperforate anus. After work up a low descending colostomy was done (4 stomas of duplicated colon) and started feeding with normal passage from colostomy.

Discussion

The cause of CDS is unknown many theories have tried to explain that, but the most accepted theory is failure of monchorial twins to separate completely. CDS may be associated with other congenital anomalies as imperforate anus, renal anomalies, and omphalocele.

Conclusion

CDS is a very rare condition which needs multidisciplinary team to manage and needs staged repair. Most pediatricians and pediatric surgeons are unable to diagnose it, we add a case of CDS to the literature.

Spine duplication or split notochord syndrome - case report and literature review

Context: Spine duplication is a rare condition, with various extents and severe additional anomalies. The goal of this study was to describe a unique case of a boy with split notochord syndrome who was followed up from birth until maturity. Findings: Physical examination at birth showed defects of the abdominal wall and cloacal exstrophy with visible urether outlets. A transposed anus was present in the perineal region. Split bony elements of the spine with nonpalpable sacral bone were noted. A soft, skin-covered lump, with the consistency of a lipoma, was present in the sacral area. There was asymmetry of the lower limbs: the left was hypoplastic, with a deformed foot and hip. Computed tomography revealed a normal shape of the Th12 and L1 vertebrae, whereas the L2 was split. Downward from L3, there were two vertebrae at each level, with two spinal canals. The spinal cord divided into two "semicords" at the level of L1. Neurologic status and the shape of the spine remained unchanged during puberty. The last follow-up was performed at the age of 18 years. He managed to walk independently in prosthesis with visible limping. Conclusion: Spine deformities are always suspected in neonates with lipoma in the sacral region, which may sometimes be serious. Walking ability and quality of life depend on neurologic deficits; even with long duplication and double sacrum, walking can be a feasible option.

Anorectal malformations and perineal hemangiomas: The Arm-Net Consortium experience

AIM

Perineal hemangiomas rarely occur in patients with anorectal malformations (ARMs), but they can pose a significant challenge and warrant special attention. Surgical incision of posterior sagittal anorectoplasty (PSARP) may involve the hemangioma site resulting in hemorrhage, damage to blood supply, leading to complications and adversely affecting outcome. The aim of this study was to review the experience of the ARM-Net Consortium in the management of perineal hemangioma associated with ARM and evaluate treatment strategies.

MATERIALS AND METHODS

Data on all patients with ARM and a perineal hemangioma located in the planes of the PSARP dissection who were managed at participating ARM-Net centers were collected retrospectively by questionnaire, as follows: ARM type, hemangioma distribution and penetration, imaging findings, medical/surgical management, timing of definitive repair, complications and outcome.

RESULTS

Ten patients from eight centers were included. Three patients each had a rectobulbar or rectovestibular fistula, 2 had a rectoperineal fistula, and one had a rectoprostatic fistula; in one patient, the hemangioma was too disfiguring to determine malformation type. Mean follow-up time was 36.6 months (median 29 months). Colostomies were performed before definitive repair in 8 patients. Five patients received systemic beta-blockers before PSARP: 3 were operated uneventfully following partial/complete involution of the hemangioma, and 2 are awaiting surgery. The two patients with rectoperineal fistula were managed expectantly. The remaining 3 patients underwent surgery with no preoperative medical treatment, and all had complications: mislocated neoanus in three and complete perineal dehiscence in one.

CONCLUSION

Attempting PSARP in the presence of a perineal hemangioma may lead to complications and adversely affect outcome. This study confirms the benefits of beta blocker treatment before surgical reconstruction.

LEVEL OF EVIDENCE

Treatment study, level III.

Surgical management of caudal duplication syndrome: A rare entity with a centered approach on quality of life

Background:

Caudal duplication syndrome (CDS) is associated with complete/partial duplication of the spine, spinal cord, duplication/malformations of other caudal structures, and often neurological dysfunction.

Case Description:

A 9-month-old with the prenatal diagnosis of multiple fetal malformations was born through cesarean section at 39 weeks. Computed tomography and magnetic resonance imaging revealed a series of abnormalities: intramedullary cyst at the L4 level with tethering of the conus with a lipoma, a duplication of the sacrum, duplication of the intestines, a ventricular septal defect, bladder duplication, four kidneys, two fully formed functional penises, two anuses (imperforate on the left), and a paramedian ossified appendage suggestive of a malformed leg. The child, at an 8 months of age, underwent a laminectomy at the L4 level for resection of the conus lipoma, release of the tethered cord, and resection of the intramedullary cyst.

Conclusion:

Spine/spinal cord duplication syndromes are typically associated with spine/spinal cord abnormalities and are often associated with moderate/severe neurological deficits. Additional malformations associated with the CDS include duplication of vascular structures/organs (e.g., bladder and distal gastrointestinal tract). Here, we focused on both the patient’s quality of life and the multidisciplinary approach to managing the duplication syndrome associated with multiple system malformations (e.g., neurological/spinal, bladder, and gastrointestinal, others).

Persistent cloaca and caudal duplication in a monovular twin, a rare case report

INTRODUCTION

A cloaca occurs when genitourinary tract and bowel converge into a common channel. We report a case of partial caudal duplication, persistent cloaca and vestigial appendage in a monovular female twin infant.

PRESENTATION OF CASE

This is a monochorinonic-diamniotic twin born at 36 weeks with apgars of 9/9. She had a duplicated labia with two clitorises, and a partially formed accessory foot with 2 toes protruding from the right gluteal region. There was anal atresia and a punctate urethral opening in the right genitalia through which she voided spontaneously. X-ray of the accessory foot had rudimentary metatarsals and phalanges. There was left hydroureteronephrosis and a hydrocolpos causing severe mass effect. On the first day of life, she had exploratory laparotomy with a diverting colostomy and mucus fistula and drainage of hydrocolpos. At 6 months of age, she had removal of the accessory foot with flap closure of the perineal defect and vesicostomy. At 15 months of age she had laparotomy for repair of cloaca, excision of presacral pelvic mass and the duplicated vulva.

DISCUSSION

Theories of etiology include failure of regression of Kovalevsky's canal (a communication that connects the amniotic and yolk sac), an incomplete form of twinning through iatrogenic damage to the zona pellucida or a failed triplet formation from a single embryo.

CONCLUSION

Caudal duplication with persistent cloaca and vestigial appendage is a rare and complex malformation. Having a unified surgical and medical team to preserve quality of life and to treat complications is of key importance.

Female Caudal Duplication Syndrome: A Surgical Case Report With 10-Year Follow-up and Review of the Literature

Caudal duplication syndrome is an exceedingly rare condition that manifests as duplicative anomalies of the gastrointestinal and genitourinary systems. We present a case of an adult patient born with multiple congenital anomalies including duplicated reproductive and urinary systems. She presented to our center for initial evaluation 11 years ago largely experiencing right-sided pelvic organ prolapse and bilateral urinary tract voiding dysfunction. She underwent successful surgical management and presented several years later for recurrent symptoms. We describe her presentation and our surgical experience, including complications and outcomes, for this case. We also review caudal duplication syndrome-its etiology, clinical presentation, diagnostic workup, surgical intervention (if any), and recommendations.